Lehighton Pool Pal Memorial Swim Fund

PO Box, Lehighton, PA 18235 Lehighton Area Lehightonareapoolpals.org Pool Pals

Lehighton Pool Pal Memorial Swim Fund Application for Season Pass

Assistance for Lehighton Baer Memorial Pool season pass is possible with generation donations and fundraising events. To apply for a family/single season pass please complete the following application.

You must meet the following criteria to apply for a season swimming pass Must have transportation to the pool.

If applying for a family pass, includes children up to and including 12th grade.

Must use the pool on a regular basis. Must reside in Carbon County. Must meet low income guidelines.

You will not be discriminated against or denied because of race, religion, color, national origin, sex, political affiliation. All sections of the application must be complete and accurate in order for the organization to review the request.

Section 1: Personal Information - Please Print all information clearly and complete all questions.

County*

Person Completing the Form*

First NameLast Name

Address*

Phone Number*

Email*

example@example.com

Total number of people in household including children*

Select One*

MinorSingleMarriedWidow/Widower

Are you applying for a family pass or a single pass?

Name of all Adults residing in the household including person filling out the form.*

If yes; Names and ages of children residing in household.*

Income for First Adult*

	Monthly Amount Received
Employment
Unemployment
Disability
SSI
Cash Assistance
Alimony
Pension
Other

Income for 2nd Adult

	Money Amount Received
Employment
Unemployment
Social Security
Disability
Child Support
Alimony
Cash Assistance
Pension
Other

Income for Additional Adult/s

	Money Amount Received
Employment
Unemployment
Social Security
Disability
Child Support
Alimony
Cash Assistance
Pension
Other

Monthly Expenses for Total Household*

	Total Monthly Amount Due
Mortgage/ Rent
Utilities
Cable
Phone
Internet
Other

Section 3: Additional Information

Do you have transportation?*

YesNo

Will you take advantage of the swimming lessons*

Not At All LikelyLikelyMost LikelyExtremely Likely

How often will you use the pool?*

Not OftenSometimesMajority Every DayEvery Day

How did you hear about this fund?*

Proof of Income*

Must submit all proof of income mentioned above. (example: W-2, Paystub, ect...)